Inside Health

M.D.'s Make Room for Others In Ranks of Psychoanalysts

By ROBERT PEAR,

Published: August 19, 1992

WASHINGTON, Aug. 18—
Following in the footsteps of Freud's daughter, scores of nonphysicians are training to become psychoanalysts under the settlement of a lawsuit that promises to transform this most intensive form of psychotherapy.

Since the early years of the 20th century, physicians, specifically, psychiatrists, have dominated the practice of psychoanalysis in the United States. For decades, the accredited training institutes of the American Psychoanalytic Association insisted that applicants have an M.D. degree before they could start training, and the institutes made only a few exceptions for academic researchers.

But in March 1985, four psychologists filed a class-action lawsuit against the association and some of its institutes, charging that they had conspired to establish a monopoly on psychoanalysis and to stifle competition in violation of Federal antitrust law. A result of the conspiracy, they said, was to raise the prices charged to patients, insurance companies and others who pay for psychoanalysis.

Analysts denied the charges. But the lawsuit was settled in November 1988, with the institutes promising not to discriminate against psychologists or other "nonmedical candidates." No specific quotas were set for such candidates.

Most of the psychoanalytic training institutes have now admitted substantial numbers of nonphysicians, and the reaction from both psychiatrists and psychologists is positive. Psychoanalysts seem not to remember why they fought so hard to exclude psychologists from their ranks, or they are unwilling to express their reservations publicly.

The new trend could benefit consumers by increasing the number of psychoanalysts, increasing competition, slowing the increase in fees and making services more affordable. A Question of Cost

Dr. Kenneth T. Calder of Manhattan, who served as president of the American Psychoanalytic Association in 1977-78, said, "Many of the non-M.D.'s do good work and charge a lesser fee."

But Dr. Arnold Goldberg, director of the Chicago Institute for Psychoanalysis, expressed concern that "some insurance companies balk at reimbursing non-M.D.'s." Many insurers are cutting back the coverage of mental illness in general, even when the treatment is given by a physician. However, some states require insurance companies to accept claims from both psychiatrists and psychologists.

Psychoanalysis, known as the talking cure, is the most intensive form of psychotherapy. Typically, it involves four or five sessions a week for several years. In the traditional form, the patient lies on a couch and has no eye contact with the analyst, whose chair is at the head of the couch.

Analysts encourage patients to say whatever comes into their minds, with the hope that the patients can understand and overcome the unconscious inhibitions that limit their ability to love, work and create.

Dr. Marvin Margolis, chairman of the board on professional standards of the American Psychoanalytic Association, said: "Many of us were already working for a more open admissions process, but the lawsuit accelerated that development. Nonmedical candidates are doing well in training. In five years, I predict, psychologists, social workers and other nonphysicians will account for 50 percent of all candidates."

Even as psychologists show new interest in psychoanalysis, the number of American medical school graduates choosing to specialize in psychiatry has declined. That number has dropped 29 percent, to 526 this year from 745 in 1988, a trend the psychiatrists are trying to reverse. Arduous Training

The training of an analyst has traditionally been long and arduous. After graduation from college, prospective analysts faced four years of medical school, four years of psychiatric training in a residency program, and four to eight years of analytic training at an institute.

Many doctors who go into psychiatry favor forms of therapy other than psychoanalysis. And many are attracted by neuroscience, the effort to explain the workings of the brain and mental illness in terms of biochemistry and cellular biology.

By contrast, Bryant L. Welch, one of the plaintiffs in the 1985 lawsuit, said: "Psychoanalysis is the fastest-growing area of interest among psychologists. Psychologists are rejuvenating psychoanalysis. They are likely to have a warmer analytic relationship with patients because they are less authoritarian than medically trained analysts."

Dr. Goldberg, the Chicago psychoanalyst, dismissed that view, saying, "To attribute anything as mysterious as warmth or authority to one group or another is a trite prejudice."

Dr. Harry R. Brickman, chairman of the education committee at the Southern California Psychoanalytic Institute in Beverly Hills, said: "We are taking a much larger number of nonmedical people. For at least two years now, physicians have been in the minority of our new classes. For this fall, we have two physicians in an entering class of eight.

"By virtue of their familiarity with the biological and psychological aspects of emotional disorder, psychiatrists are, in many ways, preferable to nonmedical therapists."